Provider Demographics
NPI:1639175292
Name:WALLACE, WAYNE O JR (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:O
Last Name:WALLACE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 RAVEN HILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-1243
Mailing Address - Country:US
Mailing Address - Phone:913-367-7300
Mailing Address - Fax:
Practice Address - Street 1:810 RAVEN HILL DRIVE
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-1401
Practice Address - Country:US
Practice Address - Phone:913-367-6689
Practice Address - Fax:913-360-5837
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0413701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098780IMedicaid
KS173470Medicare ID - Type Unspecified
KS100098780IMedicaid